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Four insurers – Blue Cross Blue Shield of North Carolina, Cigna, Ambetter, and Bright – are offering 2020 individual market plans through the North Carolina exchange. (Most of the state has a single carrier – Blue Cross Blue Shield of North Carolina – offering plans in the exchange.) Bright Health is a newcomer as of 2020, offering plans in the Charlotte and Winston-Salem areas.

Medicaid coverage in North Carolina

North Carolina is one of 14 states that still have not accepted federal funding to expand Medicaid under the ACA. An estimated 626,000 in the state would gain coverage if the state were to accept federal funding to expand the program.

Because the state refused to expand Medicaid, North Carolina has an estimated 194,000 residents in the coverage gap, with no access to Medicaid or exchange subsidies.

The Affordable Care Act in the Tar Heel State

In 2010, North Carolina’s U.S. Senators were divided on healthcare reform. Kay Hagen, a Democrat, voted yes on the ACA, while Richard Burr, a Republican, voted no. In the U.S. House, five Republican representatives from North Carolina voted no, while eight Democrats voted yes.

Burr remains in the Senate, but Hagen has been replaced by Thom Tillis, a Republican who opposes the ACA. Both Burr and Tillis voted in favor of the threeSenateversions of ACA repeal in 2017, although none of them were ultimately enacted.

And the U.S. House now includes just three Democrats from North Carolina, and ten Republicans.

Cooper replaced former Governor Pat McCrory, who had served for four years as the first Republican governor of North Carolina since 1988. McCrory’s predecessor, Governor Bev Perdue, had stated that North Carolina would enter into a partnership exchange with HHS, but shortly after he took office, McCrory announced that the state would default to a federally-facilitated marketplace.

In addition, MrCrory also decided that the state would not move forward with Medicaid expansion, citing a problematic recent audit of the state’s existing Medicaid program, and noting that the program’s issues needed to be fixed before the state considered expanding it.

McCrory was not a fan of the ACA, but early in the 2014 open enrollment period, he softened his stance a bit in a public announcement to the state’s residents. While he still noted that he was opposed to the ACA, he provided information and resources to help direct people to Healthcare.gov and enrollment assisters.

In general however, the state’s government has taken a largely hands-off role in terms of promoting and implementing the ACA in North Carolina. But a strong network of community-based public health workers, navigators, and volunteers have resulted in substantial enrollment in North Carolina’s exchange.

How Obamacare has helped NC residents

North Carolina’s refusal to expand Medicaid has resulted in an uninsured rate that is considerably higher than it would be if the state had accepted federal funds to make Medicaid available to all adults (assuming they’ve been legal U.S. residents for at least five years) with incomes up to 138 percent of the federal poverty level. But the ACA has certainly benefitted North Carolina residents who used the exchange to enroll in Medicaid or private plans. The state was one of six states that enrolled more than half of its potential market through its exchange in 2015, and has consistently had third-highest enrollment among HealthCare.gov states, and the fourth-highest among all states.

According to U.S. Census data, 15.6 percent of North Carolina residents were uninsured in 2013. That had fallen to 10.4 percent by 2016, although it had increased slightly, to 10.7 percent, by 2018 (the national average has crept up under the Trump administration).

Is there still a high-risk pool in North Carolina?

Before the ACA dramatically reformed the individual health insurance market, coverage was underwritten in nearly every state, including North Carolina. This meant that pre-existing conditions could prevent an applicant from getting coverage, or could result in significantly higher premiums or policy exclusions. The North Carolina Health Insurance Risk Pool was created in 2009 to give people an alternative if they were unable to obtain individual health insurance because of their medical history.

When ACA implementation resulted in a guaranteed issue individual market in January 2014, risk pools were no longer necessary. The North Carolina Health Insurance Risk Pool ceased operations at the end of 2013, and members were able to transition to new, ACA-compliant plans issued on or off-exchange.